Twenty-nine months ago, I set out on a quest to end my life,” says Ron, a burly, long-time musician. “I was dealing with uncontrollable moods. I sold all my guitars, all my belongings.”
Ron is recovering from heroin addiction and alcoholism. He also lives with bipolar disorder and post-traumatic stress disorder, or PTSD. “But now,” he says, “I can say that the last five months have been the best of my last 15 years. I’m comfortable in my own skin. I’m happy.”
Ron is a patient at Portland’s Old Town Recovery Center, part of Central City Concern (CCC). He’s both emotionally stronger and in better physical health. Over the past year, he has lost 40 pounds and his blood sugar, once at pre-diabetes levels, has dropped sharply.
He gives the credit to the “great communication between Kelly (Fitzgerald, his counselor), my doctor, and my nurse practitioner.”
That kind of communication is one of the goals of CCC’s year-old Integrated Health and Recovery Treatment program, or IHART. Ron is one of 200 patients in IHART, funded by a 2014 federal health system transformation grant that helped to develop a “health home” model for patients who have severe mental illness and complex medical needs.
Mental health specialists, addiction counselors, peer wellness counselors and case managers work closely with primary care practitioners to provide what’s called “wraparound” treatment for patients like Ron with mental and physical health needs.
“Traditionally, behavioral health (mental illness and substance abuse) treatment is completely separate from primary care,” says John Bischof, MD, who is CCC’s
psychiatric medical director and the IHART psychiatrist. “They’re funded separately and delivered much differently.”
But more than two-thirds of people with a mental illness have one or more chronic physical conditions, some a result of medications they take, some from lifestyle. They include obesity, high blood pressure and high blood sugar. If not monitored closely these can lead to heart disease, type 2 diabetes and early death.
“People with a major mental illness who receive publicly funded health treatment, die, on average, 25 years earlier than people in the general population,” says Bischof. “That’s unacceptable. We have to do something.”
One of the things the team does is regularly measure patients’ weight, blood pressure, blood sugar, cholesterol and smoking status, says team manager Shanako DeVoll. Then they work with primary care providers to improve patients’ health behaviors.
Each patient is also supported by a health assistant, case manager, peer wellness counselor and addiction specialist. The team meets every morning to discuss patient needs and assign tasks: patients need help getting housing, cell phones, glasses, bus passes, and food boxes. They need reminders about dental appointments, lab tests, injections.
“It’s a much more holistic view of the patient,” says Jeffrey Yoder, a peer wellness counselor. His daily tasks might include tracking down homeless patients to remind them about an injection or planning menus and grocery shopping with people who want to lose weight.
Staff check in with each other often and enjoy working as a team. “We’re on the same computer system (with primary care and mental health practitioners) so if you see someone has new medication you can go down the hall and talk to the prescriber. It makes our real-time responses a lot more on the mark,” says Fitzpatrick, who is Ron’s addiction specialist.
“About eight months ago she started a campaign to get me to play guitar and sing again,” Ron says. “She started bringing a guitar to group sessions. I wouldn’t play. But one day I got my hambone up, my hands were shaking, my throat was dry. I’ve played every group since then. I’ve received a lot of love.”
